Provider Demographics
NPI:1831127646
Name:WHEELER, KRISTAN JAN (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTAN
Middle Name:JAN
Last Name:WHEELER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:875 BLAKE WILBUR DR
Mailing Address - Street 2:MAIL CODE 5826
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94304-2205
Mailing Address - Country:US
Mailing Address - Phone:650-725-7722
Mailing Address - Fax:650-736-4176
Practice Address - Street 1:875 BLAKE WILBUR DR
Practice Address - Street 2:MAIL CODE 5826
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-2205
Practice Address - Country:US
Practice Address - Phone:650-725-7722
Practice Address - Fax:650-736-4176
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10005041363AM0700X
CAPA21918363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S32318Medicare UPIN